Provider Demographics
NPI:1265161269
Name:JACOMINO, MICHELLE LOURDES (DMD)
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:LOURDES
Last Name:JACOMINO
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:255 GALEN DR APT 3K
Mailing Address - Street 2:
Mailing Address - City:KEY BISCAYNE
Mailing Address - State:FL
Mailing Address - Zip Code:33149-1957
Mailing Address - Country:US
Mailing Address - Phone:305-979-0603
Mailing Address - Fax:
Practice Address - Street 1:29 BEE ST
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29425-0001
Practice Address - Country:US
Practice Address - Phone:843-792-1414
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-06-07
Last Update Date:2022-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL269551223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty